There is clearly a need to develop quality metrics that are relevant to the unique nature of emergency general surgery diseases. But, at the present time, there are no universally agreed upon set of quality measures for emergency general surgery. For example, evidence-based practice management guidelines have been developed for a few diseases but, they are not incorporated into routine clinical use. Surgical Care Improvement Program (SCIP) quality measures are generally meant for elective surgical cases but are also used for emergency general surgical disorders (Surgical Care Improvement Project. 2014. Available at: www.jointcommission.org/surgical_care_improvement_project. Accessed June 18, 2014).
Comprehensive measurement of quality requires multiple metrics that encompass all three domains of quality as suggested by Donabedian – structure, process, and outcome measures (JAMA 1988;260:1743-8). Such a comprehensive system may be called EQIP – Emergency General Surgery Quality Improvement Program. Some components for EQIP are the following: 1) structural metrics, i.e., the availability of trained emergency general surgeons and support staff, operating rooms, gastroenterologists and endoscopy units, interventional radiologist and interventional radiology suites, critical care services, data registry, quality oversight committee, educational programs, and standardized documentation of care; 2) process measures, i.e., the timeliness of evaluation and interventions, use of evidence-based management guidelines, appropriate use of antibiotics and blood transfusions, post–acute care follow-up, and long-term care; and 3) outcome metrics, i.e., morbidity, mortality, length of stay, readmissions, costs, functional outcomes, quality of life, return to work or school, and pain relief.
Emergency General Surgery Registry
Quality and relevant data are essential to measuring the quality of care. But, at the present time there are no universally agreed upon data elements for emergency general surgery nor is there a national registry. National Surgical Quality Improvement Program (NSQIP) and Trauma Quality Improvement Program (TQIP) have set precedence for surgical quality reporting (American College of Surgeons National Surgical Quality Improvement Program. 2014. Available at: http://site.acsnsqip.org/. Accessed June 18, 2014; J. Am. Coll. Surg. 2009;209:521-30). Unfortunately, NSQIP in its current form is not designed to capture emergency general surgery patients for the following reasons: 1) It includes only operative cases whereas a significant proportion of emergency general surgery patients may be managed nonoperatively, and 2) emergency general surgery operative cases constitute only a small proportion of the NSQIP database due to its sampling methodology. Therefore, NSQIP data should not be used to accurately measure the quality of emergency general surgery care and, therefore, a better system is needed to do so. Data elements should include the following components: 1) anatomic severity of disease; 2) physiologic status of the patient; 3) patient demographics, such as age, gender; 4) patient comorbidities; and 5) patient outcomes, such as clinical, cost, functional, and quality of life. Well-established systems, such as the SOFA measure a patient’s altered physiology and comorbidities (Crit. Care Med. 2008;36:296-327; Intensive Care Med. 1996;22:707-10; J. Chronic Dis. 1987;40:373-83; Crit. Care Med. 1985;13:818-29) but none properly provides a time-tested measure of the anatomic severity of emergency general surgery disease. To that end, the members of AAST have developed the following universal system for grading emergency general surgery diseases (J. Trauma Acute Care Surg. 2014;77:705-8):
Grade I – Local disease confined to the organ with minimal abnormality.
Grade II – Local disease confined to the organ with severe abnormality.
Grade III – Local extension beyond the organ.
Grade IV – Regional extension beyond the organ.
Grade V – Widespread extension beyond the organ.
Using this system, the members of the AAST have published a series of grades for common emergency general surgery diseases (J. Trauma Acute Care Surg. 2014;76:884-7), and this uniformity of categorizing disease severity is essential for risk adjustment, especially when comparing patient and center outcomes. It is anticipated that this system will provide the necessary elements for a more uniform assessment of patient diseases and therefore enhance quality and research efforts.
Dr. Shafi is a general/trauma surgeon at Baylor Scott & White Health System in Dallas. He was the chair of the Patient Assessment and Outcomes Committee of AAST that developed the new grading system for Emergency General Surgery (EGS) diseases. Previously, he was a member of the team that developed TQIP – Trauma Quality Improvement Program, at the American College of Surgeons.